腰椎前路手术新的右侧前中线入路

2012-02-28 文章来源:www.aaos.org 点击量:4170   我要说

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翻译:上海中山医院  戴文达
介绍:腰椎前中线入路在近几年不断发展,主要用于椎间融合和椎间盘关节成形术。这项从左侧腹膜后的入路在专业杂志已被详尽的描述和分级。主要的并发症有:逆行射精,静脉损伤和动脉栓塞。这项前瞻性的研究目的在于描述从右侧前中线的入路用于腰椎手术,下至主动脉分叉L5s1处,在L2到L5间从右向左松动腔静脉。评估其可行性和并发症的概率。
方法:这项前瞻性的研究纳入469例患者从03年8月至10年11月。手术有前路椎间融合术或全椎间盘置换术,在L23和L5s1之间,累及1个或多个节段。
结果:在154例患者行腔静脉松动术,无损伤发生。只有4例大静脉损伤发生。没有动脉并发症发生,仅有1例氧饱和度出现异常。没有逆行射精发生。
结论和讨论:与经典的经左侧入路,经右侧前中线入路是一项安全的可供选择的手术入路。与左侧浅静脉侧壁相比,腔静脉侧壁的更厚,也解释了较低静脉损伤发生率。与左侧入路相比,静脉回缩需要解剖至L45,且不会导致动脉阻塞,减少了动脉粥样硬化的概率。没有逆行射精证实了之前对从左侧对上部髂内动脉丛的吻合实验。
 
NTRODUCTION
Midline anterior approach to the lumbar spine has developed during these last years, mainly for interbody fusion and disc arthroplasty surgery. This retroperitoneal approach is well described in publications and classically made from the left side. Major complications associated with the approach are known: retrograde ejaculation, venous injuries and arterial thrombosis.The aim of this prospective study was to describe a midline anterior approach to the lumbar spine from the right side, below the aortic bifurcation to L5S1 and by mobilizing the vena cava from right to left between L2 and L5 and to evaluate the feasibility and complication rate.
METHODSA
total of 469 patients were included in a prospective study between August 2003 and November 2010, either for interbody fusion by anterior approach or for total disc replacement, on one or several levels between L2-L3 and L5-S1.
RESULTS
Of the 154 patients who had a mobilization of the vena cava, no injury occurred. Only four major venous injuries occurred. There was no arterial complication and the oxygen saturation signal was interrupted in only one case. No case of retrograde ejaculation was found.
DISCUSSION AND CONCLUSION
The midline anterior retroperitoneal approach from the right side is a safe alternative compared to the classical approach from the left side. The low rate of venous injury is explained by the sidewall thickness of the vena cava compared to the left iliac vein sidewall. Contrary to what happens by left sided approach, the vascular retraction required for access to L4-L5 and above does not lead to arterial occlusion and therefore diminishes the risk in atheromatous patients. The absence of retrograde ejaculation confirms previous studies made on the left anastomosis of the superior hypogastric plexus suggesting that its approach and mobilization by the left side is delicate.
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#1
很好!
发表于:2012-04-04 14:04:11  IP:192.168.123.207